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HARRILL AND MELON

Capturing, measuring and actively managing these evolving multi dimensional perspectives of “ value ” from these three stakeholders (the “ Big 3 ” ) within VBH can be best represented as Value = Patient Experience Management 3 (Figure 6).

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| IMPLICATIONS FOR PRACTICE

An understanding of the evolution of healthcare reform requires a historical perspective of prior reform initiatives, familiarity with the ever-changing terminology, and a recognition of primary stakeholder interests. A key theme in the journey of U.S. healthcare reform has been elevating the patient stakeholder interests and coordination-of care relationships in healthcare delivery models. As a percentage of GDP, sustainable reductions in healthcare expenditures have been demonstrably achievable when the Big 3 stakeholder interests have been aligned within healthcare reform legislation (Figure 1). 1 To suc cessfully shift from a volume-based reimbursement system to one based on value, these Big 3 stakeholder interests must be aligned, only then can reform goals of reducing healthcare cost, improving health quality and enhancing the patient experience be realized. Evolv ing “ best practice ” within developing practice guidelines, site-of-service utilization, and patient experience expectations will determine future measures of value. Understanding the working definitions and con ceptual boundaries driving VBH reform will empower physicians to have a greater role within The Big 3 stakeholders in the transition from “ volume to value ” within future alternative payment model design and implementation. BIBLIOGRAPHY 1. Centers for Medicare and Medicaid Services. National Healthcare Expen ditures by Type of Service and Source of Funds: 1960-2018 . https://www. cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and Reports/NationalHealthExpendData/NationalHealthAccountsHistorical. Accessed December 28, 2020. 2. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century . Washington, DC: National Academies Press; 2001. 3. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med . 2000;51(7):1087 1110. 4. Oneview. https://www.oneviewhealthcare.com/the-eight-principles of-patient-centered-care/. Accessed March 3, 2020. 5. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient centered primary care. J Gen Intern Med . 2005;20(10):953-957. 6. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann FamMed . 2011;9(2):100-103. 7. Constand MK, MacDermid JC, Dal Bello-Haas V, Law M. Scoping review of patient-centered care approaches in healthcare. BMCHealth Serv Res . 2014;14:271. https://doi.org/10.1186/1472-6963-14-271. CONFLICT OF INTEREST The authors have no conflicts of interest related to this review. ORCID Willard C. Harrill https://orcid.org/0000-0003-4782-1343

FIGURE 6

Value-Based Healthcare: a three-dimensional model

MACRA also recognized the role of the physician stakeholder within the coordination and management of the clinical outcomes within both population disease-severity-cost-of-care and episode-of care management. 63-65 Moving from volume-to-value within the ACO model, CMS continues to shift away from fee-for-service arrange ments toward more value-based P4P MCBR models ranging from the hybrid PBP model (both fee-for-service and value-based capitation) to the fully capitated value-based All-Inclusive Population-Based Pay ment models. 47,66 At the episode-of-care level, CMS expanded APMs with the Bundled Payments for Care Initiative, integrating an episode of-care capitated risk model linked to quality that is backed by a newly evolving third party re-insurance market to mitigate shared financial risk. 67-69 CMS is also engaging efforts to facilitate more value-based engagements between physician stakeholders. In 2021, CMS modified regulatory barriers for physicians by allowing safe-harbor exemptions for value-based arrangements within the physician self-referral law, also known as the STARK law. 70 The “ patients over paperwork ” initia tive sought to improve quality-of-care and lower costs by improving disease severity site-of-service coordination-of-care within physician driven value-based competition. 71 For the physician stakeholder, the challenges and risks within value-based healthcare are best described by Porter: “ If physicians fail to lead these changes, they will inevitably face ever-increasing adminis trative control of medicine. Improving health and healthcare value for patients is the only real solution . ” 54 The clinician's role within the physician-patient relationship is the key point of reference from which coordination-of-care and patient engagement is measured. Within VBH, coordination-of-care between these two stakeholders integrates the concepts of the PCCM and is realized through the Integrated Practice Unit for chronic disease management. 72,73 For that relation ship to yield greater measurable clinical value, the physician will need to play an increased role coordinating the development of value based models.

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